Clin: Operative deliveries - Wootton

Question 1

what are the contraindications for operative vaginal delivery?

Answer 1

• if fetal head is not engaged
• position of fetal head is unknown
• fetus is suspected to have bone demineralization condition (osteogenesis imperfecta)
• bleeding disorder suspected (alloimmune thrombocytopenia, hemophilia or VWB)

Question 2

• maternal exhaustion/lack of expulsive effort
• inability to have expulsive effort (spinal cord injuries, neuromuscular disorder)
• need to avoid maternal expulsive efforts (certain cardiac conditions)
• non-reassuring fetal status (bradycardia, repetitive decels)
• prolonged second stage of labor

Answer 2

indications for operative vaginal delivery

Question 3

what is considered a prolonged 2nd stage of labor for nulliparous mom?

Answer 3

> 2hrs without regional anesthesia

>3 hours with regional anesthesia

Question 4

what is considered prolonged 2nd stage of labor for multiparous mom?

Answer 4

> 1hr without regional anesthesia

>2hrs with regional anesthesia

Question 5

what are the maternal criteria for operative vaginal delivery?

Answer 5

• adequate analgesia
• lithotomy position
• empty bladder
• consent

Question 6

what are the fetal criteria for operative vaginal delivery?

Answer 6

• vertex position
• fetal head must be engaged (biparietal diameter at 0 station)
• position of fetal head must be known with certainty
• estimation of fetal weight performed
• station of fetal head must be > +2

Question 7

what are the uteroplacental criteria for operative vaginal delivery?

Answer 7

• cervix fully dilated
• membranes ruptured
• no placenta previa

NOTE: must also be in a facility where emergent c-section can be performed if something goes wrong

Question 8

what type of forceps used for breech presentation?

Answer 8

PIPER forceps

Question 9

leading point of the fetal head is at +2 station or more, is not on the pelvic floor (can be rotational or non-rotational)

Answer 9

LOW operative vaginal delivery

Question 10

fetal skull is above +2 station

Answer 10

midpelvis and high forceps operative vaginal delivery

- NOT EVER INDICATED TODAY

Question 11

forcep blades should fit the fetal head evenly

- should lie against what?

Answer 11

the fetal head so that they cover the space between the orbits and ears

Question 12

how is traction applied with forceps?

Answer 12

in the plane of least resistance
- follows the pelvic curve

IF IT DOESN’T COME EASY -> STOP

Question 13

• laceration of the vagina/cervix
• episiotomy extension
• pelvic hematomas
• urethral and bladder injuries
• uterine rupture

Answer 13

maternal complications of forceps delivery

Question 14

• minor facial lacerations
• forceps marks
• facial and brachial plexus injuries
• skull fracture
• intracranial hemorrhage

Answer 14

fetal complications of forceps delivery

Question 15

what is the advantage to vacuum assisted vaginal delivery?

Answer 15

delivery can be achieved with little maternal analgesia

same indications/requirements as forceps

Question 16

what are the contraindications to vacuum delivery?

Answer 16

• gestational age <34 wks
• suspected fetal macrosomia
• suspected fetal coagulation disorder
• breech presentation

Question 17

vacuum is applied to fetal head with mechanical pump 2cm anterior to what?

Answer 17

• *the posterior fontanelle and centered over the sagittal suture**
• steady traction
• no rocking or torque on device
• 5% incidence serious complications

Question 18

what 3 checks should be undertaken with vacuum extractor?

Answer 18

1. no maternal tissue trapped in cup
2. cup should be placed in midline of sagittal suture
3. vacuum port of the suction cup should point toward to occiput

NOTE: no more than 2 “pop offs” allowed, should not be applied more than 20 mins, no torsion or twisting of device

Question 19

which of the two operations have:

• more failed deliveries
• fewer perineal injuries
• increased incidence of fetal cephalohematoma
• more scalp lacerations and bruising

Answer 19

vacuum (compared to forceps)

Question 20

sequential use of vacuum extractor and forceps has been associated with what?

Answer 20

increased risk of neonatal complications and should NOT be performed routinely

Question 21

what is the most common operative procedure in the US?

Answer 21

c-section

Question 22

why is the c-section rate climbing?

Answer 22

repeat c-sections, continuous electronic fetal monitoring, macrosomia, decreased use of vaginal delivery methods, assisted reproductive technology, fear of litigation

Question 23

• non-reassuring FHR
• breech presentation/transverse
• very low birth weight (<1500g)
• active HSV infection
• immune thrombocytopenia purpura
• congenital anomalies

Answer 23

fetal indications for c-section

Question 24

• cephalopelvic disproportion
• failure to progress
• placental abruption
• placenta previa (other placental abnormalities like vasa previa)

Answer 24

maternal-fetal indications for c-section

Question 25

• obstructive benign and malignant tumors
• large vulvar condyloma
• abdominal cervical cerclage
• prior vaginal colporrhapy (repairing defect in vaginal wall)
• conjoined twins

Answer 25

maternal indications for c-section

Question 26

what are the 3 abdominal incision locations named (from closest to belly button down to pubic bone)

Answer 26

• Maylard
• Joel-Cohen
• Pfannenstiel

Question 27

what are the c-section intraoperative complications?

Answer 27

• uterine artery lacerations
• bladder injuries
• ureteral injuries
• GI tract injury
• uterine atony
• placenta accreta
• cesarean hysterectomy

Question 28

what are the post-op complications of a c-section?

Answer 28

• endomyometritis
• wound complication
• urinary complications (retention, infection)
• GI complication (ileus, diarrhea)
• thromboembolic disorders (pulm emboli/DVT)